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Sa-Ahm Five Element Acupuncture

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 J Acupunct Meridian Stud 2010;3(3):203−213

E D UCATI ON

Sa-Ahm Five Element Acupuncture

Chang-Beohm Ahn1*, Kyung-Jun Jang1, Hyun-Min Yoon1, Cheol-Hong Kim1,
Young-Kwang Min1, Chun-Ho Song2, Jang-Cheon Lee3
1
Department of Acupuncture and Moxibustion, College of Oriental Medicine Dongeui University,
Busan, Korea
2
Department of Meridian and Acupoint, College of Oriental Medicine Dongeui University, Busan, Korea
3
Division of Pharmacology and Prescriptionology, School of Oriental Medicine,
Pusan National University, Busan, Korea

Received: Jul 5, 2010 Abstract

Accepted: Jul 15, 2010
KEY WORDS:
comparing-pulse
diagnosis;
differential diagnosis;
Five-Shu points;
meridian therapy;
tonification and sedation
This study aimed to review the clinical basis for Sa-Ahm Five Element acupuncture.
This form of acupuncture uses the Five-Shu acupoints and the tonification-sedation
treatments based on the creation and control cycles of the Five Elements. A total
of 28 books and papers from the ancient “Nan-Ching” to the modern “Medical
Acupuncture” were used to study clinical practices. Sa-Ahm Five Element acupunc-
ture could be practiced in different ways depending upon differential diagnoses.
These diagnoses include theories of excess and deficiency of Yin and Yang, seven
emotions, ZangFu (organ, viscera), and comparing pulse diagnosis and meridian
therapy to meridian palpation. Clinical trials and guidelines for the practice of
Sa-Ahm acupuncture should be created to allow for a more evidence-based clinical
approach to using this technique.

1. Introduction About 360 years ago, a Korean named Sa-Ahm [4]

Sa-Ahm’s acupuncture treatment consists of defi-
ciency/excess treatments and coldness/heat treat-
ments in which Five-Shu (Five-Transporting or 5-Shu)
points are used according to tonification and seda-
tion. This principle is based on creation and con-
trol cycles of the Five Element theory, as well as
Nanjing’s theories presented in the 50th and 69th
issues [1].
Gao-Wu, in the Ming Dynasty of China (1519 A.D.),
was the first acupuncturist to tonify deficiency and
to sedate excess on the basis of either depletion or
repletion of the promotion cycle. This technique has
been referred to as the “four-needle method” [2,3].
proposed Five Element acupuncture, which simul-
taneously uses the Five-Shu points of promotion
and control cycles, and is also known as the “four-
needle technique” [5] or the “eight-needle method”
[3]. Clinically the Five-Shu points mostly focus on de-
ficiency and excess treatments although these points
can also be used for coldness and heat treatments.
Lee [6,7] proposed the diagnosis of comparative
pulse in the 1960s and Kim [8] proposed symptom-
based diagnosis. In particular, Kwon [9] used Sa-Ahm
Five Element acupuncture (SAFEA) in constitutional
acupuncture and Kim [10] proposed mind-based
SAFEA. Detailed guidelines for symptom patterns
need to be established, as there are many ways to

*Corresponding author. Department of Acupuncture and Moxibustion, College of Oriental Medicine, Dongeui University, Busan, Korea.
E-mail: cbahn@deu.ac.kr

©2010 Korean Pharmacopuncture Institute

204
select Five-Shu points from various interpretations
of Five Element acupuncture [1].
Other similar treatment methods have been de-
rived using Five-Shu points as a means of tonifica-
tion and sedation. These include meridian therapy
[11] and Five-Element constitutional acupuncture
[4]. Although Ahn [12] and Kim [10] have proposed
criteria for the Sa-Ahm’s treatment, Sa-Ahm’s acu-
puncture is generally used today in accordance
with viewpoints held by Korean practitioners with-
out a clear set of differential diagnoses. This re-
view will briefly cover Sa-Ahm’s clinical treatment
to allow for more effective use of this technique
and to allow this treatment method to be under-
stood in detail.
2. Sa-Ahm’s Clinical Treatment
2.1. Meaning and efficacy of Five-Shu
points
2.1.1. Correlations of meridian’s congenital
energy with exterior-interior,
root-trunk, path of meridian and
Five-Shu points [12]
Meridian energy consists of congenital and ac-
quired energy. The limbs below the elbows and
knees are where the interior, root and fibula me-
ridian paths are located. The congenital energy re-
flects on itself in the limbs below the elbows and
knees, and the root of six yin meridians are found
in the extremities. The yin meridians receive the
congenital energy from each meridian. Even though
the direction of the 12 meridians is divided into
along and against the stream of Five-Shu points, the
flow of Five-Shu points begins at the tips of the fin-
gers and feet, regardless of yin or yang meridian.
Distal, Five-Shu, accumulation, and alarm points are
located in the limbs, below the elbows and knees.
These points belong to the categories of interior,
root and fibula paths, and are used in treatments
for the head and trunk, as well as ZangFu.
Acupoint efficacy is divided into local or distal
actions. The distal points located below the elbow
and knee joints have distal effects for treating the
ZangFu, which are also located distally. The source
point, the Back-Shu point and the alarm point, one
each in six Zang, as well as three lower sea points,
Back-Shu point and alarm point in six Fu diseases.
The selection of acupoint located below the elbow
and knee joints allows a distal acupuncture effect,
including Five Element acupuncture, Yeonggu eight
extra acupuncture and Bidung eight extra acupunc-
ture and Tegeok constitutional acupuncture. These
effects may be understood from the viewpoint
C.B. Ahn et al
of congenital energy, which constitutes meridian
energy along with acquired energy.
2.1.2. Understanding biomedical acupuncture
The powerful effects of acupoints located below
the elbow and knee joints can be understood on the
basis of neurological findings. As the limbs below
the elbows and knees occupy larger areas in the
sensory gyrus in the brain, so the acupoints below
the elbows and knees also occupy a larger area in
the cortical representation of the postcentral sen-
sory gyrus in the brain [13].
2.1.3. Powerful energy polarity
Points between the finger tip and elbow or tip of the
toe to the knee are among the most energetically
powerful points of the body. These include the five
transporting points and also the connecting and
accumulation points as the polarity of energy is
changing from Yin to Yang or Yang to Yin. These
points are where the greatest therapeutic effects
can occur [3].
2.1.4. Energetic action
The energetic action of points situated along the
section of channel between fingers/toes and elbows/
knees is much more dynamic than other points be-
cause the energy changes from Yin to Yang or Yang
to Yin. The change in polarity and superficiality
of the channel at the extremities accounts for the
particularly dynamic action of the points at the
fingertips and toes. These points are therefore
frequently used in clinical practice [14].
2.2. Differential diagnosis according to
Kim Dong-Pil [8]
The differential diagnosis for various symptoms and
their tonification and sedation are presented in
Tables 1 and 2.
2.3. Acupuncture stimulation [8]
Sa-Ahm Five-Element acupuncture can be applied
together with stimulation techniques such as res-
piratory, rotational and directional methods (Table
3). Each stimulation, which results in tonification
or sedation, is described below.
2.3.1. Rotational stimulation
Tonification and sedation occur depending upon
clockwise or counter-clockwise rotations in accord-
ance with direction of meridians (Table 3).
Five Element acupuncture 205

Table 1 Tonification and sedation for coldness and heat

Differentiating symptom Coldness Heat

Five phases Five Zang Yin Yang Pulse Tonification Sedation Tonification Sedation

Wood Liver system Yin E & Yang D Deep S15 & GB38 KI10 & LI18 BL66 & GB43 HE8 & LI2
Yin E & Yang D Float HE8 & LI2 BL66 & GB43 KI10 & LI8 SI5 & GB38
Fire Heart system
Monarch Yin E & Yang D Deep SI5 & BL60 KI10 & HT3 BL66 & SI2 HT8 & KI2
Yin E & Yang D Float HT8 & KI2 BL66 & SI2 KI10 & HT3 SI5 & BL60
Minister Yin E & Yang D Deep TE6 & BL60 KI10 & PC3 BL66 & TE2 PC8 & KI2
Yin E & Yang D Float PC8 & KI2 BL66 & TE2 KI10 & PC3 TE6 & BL60
Earth Spleen system Yin E & Yang D Deep SI5 & ST41 KI10 & SP9 BL66 & ST44 HT8 & SP2
Yin E & Yang D Float HT8 & SP2 BL66 & ST44 KI10 & SP9 SI5 & ST4
Metal Lung system Yin E & Yang D Deep SI5 & LI5 KI10 & LU5 BL66 & LI12 HT8 & LU10
Yin E & Yang D Float HT8 & LU10 BL66 & LI2 SI5 & LI5 SI15 & LI5
Water Kidney system Yin E & Yang D Deep SI5 & BL60 KI10 & HT3 BL66 & SI2 HT8 & KI12
Yin E & Yang D Float HT8 & KI2 BL66 & SI2 KI10 & HT3 SI15 & BL60

E = excess; D = deficiency.

Table 2 Tonification and sedation for deficiency and excess

Differentiating symptom Deficiency Excess

5 phases 5 Zang Yin Yang Pulse Tonification Sedation Tonification Sedation

Wood Liver system Yin E & Yang D Deep BL66 & GB43 LU8 & LR4 LI1 & GB44 HE8 & LI2
Yin E & Yang D Float KI10 & LI8 LI1 & GB44 LU8 & LR4 SI5 & GB38
Fire Heart system
Monarch Yin E & Yang D Deep GB41 & SI3 KI10 & HT3 BL66 & SI2 SP3 & HT7
Yin E & Yang D Float LR1 & HT9 BL66 & SI2 KI10 & HT3 ST36 & SI8
Minister Yin E & Yang D Deep GB41 & TE3 KI10 & PC3 BL66 & TE2 SP3 & PC7
Yin E & Yang D Float LR1 & PC9 BL66 & TE2 KI10 & PC3 ST36 & TE10
Earth Spleen system Yin E & Yang D Deep SI5 & ST41 LR1 & SP1 GB41 & ST43 LU8 & SP5
Yin E & Yang D Float HT8 & SP2 GB41 & ST4 LR1 & SP1 LI1 & ST45
Metal Lung system Yin E & Yang D Deep ST36 & LI1 HT8 & LU10 SI5 & LI5 HT8 & KI10
Yin E & Yang D Float SP3 & LU9 SI5 & LI5 HT8 & LU10 BL66 & LI2
Water Kidney system Yin E & Yang D Deep LI1 & BL67 SP3 & KI3 ST36 & BL40 LR1 & KI1
Yin E & Yang D Float LU8 & KI6 ST36 & BL40 SP3 & KI3 GB41 & BL65

E = excess; D = deficiency.

Table 3 Rotating stimulation in Sa-Ahm acupuncture for males*

Left hand Yang meridian
Right hand Yin meridian
Right foot Yang meridian
Left foot Yin meridian
To tonify: rotate clockwise To tonify: rotate counter-clockwise
AM PM
To sedate: rotate counter-clockwise To sedate: rotate clockwise

Left hand Yin meridian
Right hand Yang meridian
Right foot Yin meridian
Left foot Yang meridian
To tonify: rotate counter-clockwise To tonify: rotate clockwise
AM PM
To sedate: rotate clockwise To sedate: rotate counter-clockwise

*For female, it is the opposite.

206
2.3.2. Respiratory stimulation
Tonification occurs following the insertion of a nee-
dle as the patient exhales and removal of inhalation.
Sedation occurs on insertion of the needle as the
patient inhales and removal on exhalation.
2.3.3. Directional insertion
Tonification occurs when the needle is inserted in
the inclined position following the direction of the
flow of energy in the meridian. By contrast, seda-
tion occurs following insertion of the needle in the
inclined position in the opposite direction to the
flow of energy in the meridian.
In theory, the use of acupuncture stimulation
may be possible in treatment but strong technical
movements on acupoints located on shallow body
surfaces, i.e. between finger tips and elbow or tips
of toes and knee, may be hard for the practitioner
to access. Clinically it is recommended that practi-
tioners do not use strong stimulations.
3. Discussion
3.1. Clinical application of Sa-Ahm
Five Element acupuncture
The clinical study of Five-Element acupuncture
can be divided into three parts: the efficacy of the
Five-Shu points, differential diagnoses and clinical
application.
3.1.1. Efficacy of Five-Shu point
acupuncture
The importance of Five-Shu points is based on
their location. Acupoints, including the Five-Shu
points, which are located below the elbows and
knees, account for the powerful polarity as well
as an energetic action, due to their change in
polarity and superficiality of the channel at the
extremities [3,14].
The particular function of the Five-Shu points
has also been explained in terms of corresponding
brain regions. Acupoints below the elbows and knees
occupy a larger area in the cortical representation
of the postcentral sensory gyrus in the brain and
also contain more sensory receptors. Needling
stimulation to these points may, therefore, induce
a greater reaction and activity in the brain. This
principle clearly supports the concept of using cer-
tain acupoints below the elbows and knees (the
so-called Five-Shu points in the classic meridian
system) as diagnosis and treatment points during
acupuncture [13].
C.B. Ahn et al
Ahn et al believe that acupuncture points below
the knees and elbows, including the Five-Shu, ac-
cumulation, connecting, alarm, lower sea and eight
points belong to the categories of interior, root and
the fibular pathways [12]. These acupoints can treat
diseases relating to the ZangFu organ and the head/
trunk, and therefore Five-Element acupuncture using
Five-Shu points may have more efficacy than other
acupuncture treatment. The function of points be-
low the elbows and knees needs to be viewed in
terms of interior-exterior and root-trunk in relation
to the Yin-Yang 11 meridian and foot-arm 11 merid-
ian, which are the forms of the 12 regular meridians.
The flow of interior-exterior, root-trunk, Yin-Yang 11
meridian, foot-arm 11 and Five-Shu points are cen-
trifugal, as these meridians are understood to flow
from the beginning of the meridian at the tip of the
extremities, moving into the trunk and head [12].
3.1.2. Differential diagnosis
The scope of Sa-Ahm’s treatment can be extensive
because of its diverse laws, such as the promotion
and inhibition cycle among the Five-Elements and
their connected meridians. The meridian consists
of three parts, that is, arm or foot, more or less of
Yin and Yang, and one of six Zangs (organs) and six
Fus (bowels).
A total of 24 deficiency and excess symptoms
exist across the six Zang and six Fu, but theories
related to these symptoms are too arbitrary to as-
sist in making a diagnosis. Although there are cur-
rently many clinical books on Sa-Ahm acupuncture
in Korea, a definitive general standard for the se-
lection of symptom patterns has not yet been pro-
posed. The general use of Sa-Ahm acupuncture has
previously been discussed in 1985 [12]. The method
can be used mainly from a theoretical viewpoint of
ZhangFus, etiology of disease as well as the more or
less of 3 Yang and 3 Yin. For example, in the case
of knee pain, we can use liver tonification (mostly
deficiency) because, according to theory of ZangFu,
the liver controls the muscles and joints. Secondly,
in the case of headache due to increasing liver-yang,
we may use liver sedation (mostly excess) given the
etiology of the disease. Furthermore, in the case
of backache due to dampness, we can use either
spleen-sedation (excess) to sedate dampness or Yang
Ming-tonification (deficiency of large intestine or
stomach) to tonify dryness from the principle of
more or less than 3 Yang and 3 Yin.
The above three viewpoints cannot fully explain
Sa-Ahm acupuncture, so a common differential di-
agnosis shared by many acupuncturists needs to be
determined. Lee was the first to propose a differ-
ential diagnosis of deficiency and excess by simul-
taneously comparing six pulses of both wrists in the
Five Element acupuncture
1960s [7]. However, his diagnosis was only focused
on deficiency and excess, neglecting coldness and
heat. Although he said that irregular forms of treat-
ments were the manifestation of subtle changes in
diseases, signs and symptoms are needed to support
his assertions. Jae-won’s comparative pulse diagno-
sis is very original in attempting to determine dif-
ferent symptoms, but a diagnosis made only using
the pulse method is difficult. Comparative pulse
diagnosis can therefore be an important guide in
using Sa-Ahm acupuncture, despite its weakness.
Kim [8] stated that he proposed the diagnosis
method called “Sa-Ahm Five-Element acupuncture
of disease symptoms,” which differentiates symp-
toms by simultaneously comparing pulse, as he
found that original Sa-Ahm acupuncture could not
cope with changes in diseases. The diagnosis of dis-
ease and the factual results of that treatment are
of no avail. He asserted that a floating pulse showed
Yang excess and Yin deficiency, while a deep pulse
demonstrated Yin excess and Yang deficiency on the
basis that the medial pulse is neither floating nor
deep, and is the manifestation of health. Kim also pro-
posed, from his clinical experience, that more focus
needs to be placed on the symptom of coldness-
heat rather than the symptom of deficiency-excess
when differentiating these two symptoms. This can
be achieved by comparing both the right and the
left Guan pulses. If the right Guan pulse is weaker
than the left, the symptom is related to coldness-
heat, while if the left Guan pulse is weaker than
the right Guan pulse, the symptom is related to
deficiency-excess. For example, looking at the symp-
tom of coldness-heat, if the pulse is floating, the
main symptom is Yang excess and Yin deficiency. The
treatment is then to firstly to tonify the fire within
the Yin meridian and to secondly sedate the coldness
within the Yang meridian. In the heat symptom, if
the pulse is deep, the main symptom is Yin excess
and Yang deficiency. The treatment is to firstly ton-
ify the coldness within the Yang meridian and to
secondly sedate the heat within the Yin meridian.
The acupoints need to be explained in detail. If
we use Yin Deficiency and Yang Excess in liver cold-
ness as an example (Figure 1), treatment includes
tonification of the fire points in the Yin meridians
(the liver-self meridian and heart-fire meridian)
using the acupoints HT8 and LR2. Second, the water
points of the Yang meridians (gallbladder-couple
meridian and bladder meridian) are sedated using
the points BL67 and GB43.
If we take Yang Deficiency and Yin Excess in
liver heat as an example (Figure 1), treatment in-
cludes tonification of the Water points of the Yang
meridian (the gallbladder-self meridian and blad-
der meridian) using the points BL67 and GB43. We
then sedate the fire points the Yin meridians (the
207
liver-self meridian and heart-fire meridian), using
the points HT8 and LR2. These rules for coldness
and heat can also be applied in the treatment of
other meridians.
Yin Deficiency and Yang Excess in spleen defi-
ciency (Figure 2) can be treated firstly with the toni-
fication of the motherly points (fire) of the mother
meridian (heart), as well as the motherly (fire) point
of the self meridian (spleen) using the points HT8
and SP2. Secondly, the suppressor (wood) point of
the stomach meridian is dispersed, as well as the sup-
pressor (wood) point of the suppressor (gallbladder)
meridian among its related Yang meridians. The
points ST43 and GB41 should be used. These rules
for deficiency and excess can also be applied in
the treatment of other meridians (Figure 2).
3.1.3. Clinical use and stimulation techniques
in Five Element acupuncture
Kim’s acupuncture treatment [8] is characteristic
of simultaneous pulse diagnosis. It compares Guan
pulses to determine coldness-heat or deficiency-
excess, but is still based on the original Sa-Ahm
acupuncture treatment. The method used by Kim
is more detailed than that of Lee [6,7] in that Kim
used differentiation of coldness-heat and deficiency-
excess and set the criterion for Yin-Yang balance by
standardizing medial pulse. Kim’s theory is still con-
tentious and not fully accepted as a standard of
general treatment as it is difficult to decide differ-
ential symptoms by pulse diagnosis only. The merit of
Kim’s treatment can be understood as a great con-
tribution to the objective use of Sa-Ahm acupunc-
ture in spite of its weakness, which is on pulse-only
diagnosis.
Seem [15] also believes that treatments using the
four-needle technique are very powerful, and should
only be pursued when a strong energetic manipu-
lation is required, and only when one is certain of
the primary element or phase affected. This recom-
mendation is because the four-needle technique
tonifies twice, then disperses twice, leading to a
very concentrated tonifying- or dispersing-action on
the affected element and meridian. If one is not
certain of the primary affected element, it is far
more conservative to use more gentle tonification
and dispersal points.
Generally speaking, Sa-Ahm treatment prima-
rily focuses on deficiency-excess symptoms rather
than those of cold-heat symptoms, although the re-
lationship between the deficiency-excess and cold-
heat symptoms needs to be studied in detail in order
to create reasonable guidelines for effect-friendly
treatments. As there are many different ways to
select Five-Shu points from the various opinions
concerning Five-Element acupuncture, we need to
208
Figure 1 Tonification and dispersal for coldness and fire
Treatment for coldness
Pulse float—Yin Deficiency and Yang Excess in the case of liver coldness
(1) Treatment rule: first, tonify its fire among
Yin meridians
(2) Treatment meridian: fire points of heart and
liver meridians
(3) Selected points: HT8 and LR2
Treatment for heat
Pulse deep—Yang Deficiency and Yin Excess in the case of liver’s heat
(1) Treatment rule: first, tonify its coldness among
Yang meridians
(2) Treatment meridian: water points of bladder and
gallbladder meridians
(3) Selected points: BL67 and GB4
Figure 2 Tonification and dispersal for deficiency and excess
Treatment for deficiency
Pulse float—Yin Deficiency and Yang Excess in spleen deficiency
Tonification
(1) Treatment rule: first, tonify its motherly point in
self- and mother meridians
(2) Treatment meridian and point: motherly (fire) point
of mother (heart) meridian as well as motherly (fire)
point of self-meridian (spleen)
(3) Selected points: HT8 and SP2
Treatment for excess
Pulse float—Yin Deficiency and Yang Excess in liver excess
Tonification
(1) Treatment rule: first, tonify its suppressor point in
its related suppressor Yin meridian
(2) Treatment meridian and point: suppressor (metal)
point of liver meridian as well as suppressor (metal)
point of suppressor (lung) meridian
(3) Selected points: LU8 and LR4
determine detailed guidelines for patterns of symp-
toms in the future.
The main stimulation techniques are rotation
(twisting), respiration (inhalation-exhalation), in the
direction of and opposite to the flow of the merid-
ian. These techniques can be used in clinic as with
other acupuncture treatments. But they are hard
to use as the points of Sa-Ahm are located on shal-
low skin-deep sites beneath the knee and elbow.
Nevertheless, a simple and weak stimulation seems
to be enough to gain the acupuncture effect.
C.B. Ahn et al
(1) Treatment rule: second, sedate its coldness among
Yang meridians
(2) Treatment meridian: water points of bladder and
gallbladder meridians
(3) Selected points: BL67 and GB43
(1) Treatment rule: second, tonify its fire among
Yin meridians
(2) Treatment meridian: fire points of heart and
liver meridians
(3) Selected points: HT8 and LR2
Sedation
(1) Treatment rule: second, disperse its suppressor
point in its suppressor-related Yang meridians
(2) Treatment meridian and point: suppressor (wood)
point of stomach meridian as well as suppressor
(wood) point of suppressor (gallbladder) meridian
(3) Selected points: ST43 and GB41
Sedation
(1) Treatment rule: second, sedate its child point in its
child-related Yang meridian
(2) Treatment meridian and point: child (fire) point of
gallbladder meridian as well as child (fire) point of
child (small intestine) meridian
(3) Selected points: GB38 and SI5
3.2. Perspectives of acupuncture treatments
Most illnesses contain interruptions manifested by
stagnation and irregularities and also imbalances
caused by deficiency and excess through the me-
ridian network. Acupuncture treatments, there-
fore, must cover these two aspects of illness to
achieve acupoint efficacy and function of sedation-
tonification. In order to gain greater efficacy, we may
combine acupuncture, based on acupoint efficacy,
and the Sa-Ahm treatment, which is based on the
Five Element acupuncture
tonification-sedation effects, to simultaneously cor-
rect interruptions and imbalances. In relations to the
principles of acupuncture treatments, we propose
that acupuncture based on acupoint efficacy to cor-
rect interruptions be called “branch treatment,” and
acupuncture based on tonification-sedation effects
to correct imbalances be called “root treatment.”
Effective acupuncture treatment, therefore, is a
combination of acupoint efficacy with Five Element
acupuncture, that is, Sa-Ahm five acupuncture can-
not be a more effective method without the coor-
dination of acupoint’s efficacy.
Also, we may understand the functions of
acupuncture based on the mechanism for acupunc-
ture analgesia proposed by Stux and Pomeranz
[16]. Acupuncture’s mechanisms are connected to
three centers, i.e. the spinal cord, midbrain, and
hypothalamic-pituitary gland. Acupuncture on local
acupoints activates all three centers. Acupuncture
on distal points activations the midbrain and
hypothalamic-pituitary gland. Given this view on the
acupuncture mechanism, acupuncture analgesia
could be better achieved using local and distal points.
Seem [15] believes that a local point directs the
treatment strategy to the affected energetic func-
tional sphere or zone (in internal energetic distur-
bances) while the distal points serve to determine
the nature of the energetic manipulation (such as
tonification, dispersal, warming, cooling, harmoniz-
ing). The combination of local and distal points forms
a pattern of treatment that resembles the pattern of
the disharmony being treated. In its most sophisti-
cated application, a treatment pattern and its
effects will confirm the diagnosis of the pattern
of disharmony.
In order to give more effective acupuncture treat-
ments for other diseases, combination methods that
cover local, special and distal points should be used
to increase efficacy and treat tonification or sedation
for imbalances. More effective treatment when using
Sa-Ahm Five-Element acupuncture could be achieved
if Sa-Ahm Five-Element acupuncture was used as a
root treatment to correct imbalances, while local
points, special points and symptomatic treatments
as branch branch treatment to correct interruptions
in proper stimulation techniques.
Various prominent acupuncturists have used these
types of acupuncture point combinations for the
treatment of backache. Ross [3] has used the follow-
ing distal points for the treatment of back pain, BL40,
59, 60, 62, KI.3, 6, 7, SI.3, SP.3, GV.26, in combina-
tion with these local points, BL, 22-19, BL.31, 34, 52,
54, GV.2−5. Stux and Pomeranz [16] have used GV.3,
4, 20, BL. 23, 25−7, 32, 36, 37, 40, 54, 57, 58, 60 and
Ah-Shi points to treat pain along the BL channel.
Pain along the GB meridian was treated using the
GV.3, 4, 20, GB. 30, 31, 34, 39, LI.4 acupoints [17].
209
3.2.1. Sa-Ahm Five Element
acupuncture [12]
Sa-Ahm Five Element acupuncture is primarily fo-
cused on Five-Shu points, which is in stark contra-
diction to other treatments. For example, backache
can be caused by disturbances of the urinary blad-
der meridian, so we use tonification or sedation of
the UB meridian depending upon deficiency or ex-
cess. Also, backache can be caused by weakness of
the kidney meridian, which we then treat by using
tonification of the KI meridian. Finally backache is
caused due to excessive dampness of the spleen,
which can be diagnosed in obesity. We can then use
tonification of the dry large intestine meridian or
stomach meridian in order to make dampness dry.
Sedation of the damp spleen meridian can also be
used on rare occasions. The selection of tonification
or sedation depends wholly upon the diagnosing
practitioner.
Backache is generally associated with kidney
or urinary bladder functions. The Governor vessel,
Du-Mai vessel and Gallbladder meridian, with little
connection to other meridians, can also be involved
in backache. Ross [3] and Stux and Pomeranz [16]
treated backache according to the traditional meth-
ods, but approximately 350 years ago Sa-Ahm treated
backache using a novel approach. He related back-
ache to the malfunction of connected organs (i.e.,
the bladder, kidney and gall bladder) to the imbal-
ance of Yin and Yang (6 Qi) while primarily using
Five-Shu acupuncture points. We cannot but won-
der how the combination of the acupoints distal to
the elbow and knee joints can treat diseases such
as backache, shoulder pain and so on. We may be
able to understand this effect using Yun-Tao-Mao’s
neurobiological fact: as the limbs below the el-
bows and knees occupy larger areas in the sensory
gyrus in the brain and the acupoints below the el-
bows and knees contain more sensory receptors, so
needling stimulation to these points may induce a
greater reaction and activity in the brain. This prin-
ciple clearly supports the concept of using certain
acupoints below the elbows and knees (the so-
called Five-Shu points in the classic meridian system)
as diagnosis and treatment points during acupunc-
ture treatment.
The points between the fingertip and elbow or tip
of the toe and knee are among the most energeti-
cally powerful points of the body [3]. They include
not only the Five-Transporting points, but also the
connecting points and the accumulation points. This
is said to be because between the fingers and el-
bows, or between toes and knees, the polarity of the
energy is changing from Yin to Yang or Yang to Yin,
and where polarity is changing is where the greatest
therapeutic effects can be made.
210
As meridian theory is based on the Qi thesis of
Yin-Yang and Five Element among organs, acupunc-
ture treatment cannot be separated from these
viewpoints. The clinical use of Sa-Ahm’s acupunc-
ture treatment seems to be core to oriental medi-
cine as Sa-Ahm acupuncture is based on the control
of Qi and blood among organs and channels. As the
creation of blood originates from the energy, one
could argue that the energy includes the blood, so
the effect of Sa-Ahm Five Element acupuncture can
be said to harmonize the function and flow of energy.
The treatment protocol of Sa-Ahm which is fo-
cusing mainly on tonification and sedation of Five-
Shu point with main points firmly based on regular
pattern, has a strong effect on imbalances of ZangFus,
but little effect on diseases of interruption such
as stagnation and irregularities in meridian net-
works. Thus, he also used points other than Five-
Shu point.
Lee [6], Kim [8] and others [17] proposed a new
form of Sa-Ahm Five Acupuncture treatment that in-
volved diagnosing symptoms after pulse diagnosis
(i.e., comparing measures six pulses). Although this
method created a new approach to Sa-Ahm treat-
ment, more verification is necessary before it is
determined as a practical diagnostic method.
There are other acupuncture treatments using
Five-Element combinations: meridian therapy, which
originated in Japan [11], and constitutional acu-
puncture originating from Korea and England [5,9].
Study into the relationship between these two forms
of acupuncture and Sa-Ahm acupuncture treatment
is necessary in the future.
Denmei asserted the use of meridian therapy by
using tonification and sedation of acupuncture after
six-position pulse diagnosis [11]. He used root treat-
ment based on tonification and sedation for four
different deficiencies of the yin meridian (liver,
spleen, lung and kidney), as well as symptomatic
treatment that was based on symptoms and the
stimulation of tender points. Denmei believes that
the root treatment comes first and the symptomatic
treatment second. Although Kim [8] and Shudo [11]
used pulse diagnosis, their viewpoints are different
in that Kim set a symptom of coldness-heat as well
as a symptom of deficiency-excess for each 12
ZangFu respectively, according to pulse diagnosis.
By contrast, Shudo set a symptom of yin meridian
deficiency and yang meridian excess primarily, with
little diagnosis of yin meridian excess.
There is another traditional Japanese acupunc-
ture meridian therapy [18] that is similar to that
of Shudo Denmei. Acupuncturists of the Society
of Traditional Japanese Medicine including Koei
Kuwahara, Okada Meiyu, Okabe Somei and others
summarized the traditional acupuncture treatment
that was practiced in Japan in 1997. The members
C.B. Ahn et al
of the Society and Shudo Denmei did differ from
each other in that they set each pattern of imbal-
ance respectively, although they did apply meridian
therapies in treatment. Shudo Denmei primarily
treated a pattern of yin meridian deficiency without
using yin meridian excess, via the use of 11 differ-
ent kinds of yin meridian deficiencies with little
connection to excess. Shudo Denmei also used root
treatment of yang meridians, which consists pri-
marily of dispersing excess, in contrast to the prac-
tice that uses liver excess pattern in relation to
spleen and lung deficiencies. As there seems to be
some confusion, the differences between the two
meridian therapies should be studied in order to
achieve more effective clinical treatment and to
understand why the methods used by Shudo Denmei
and Sa-Ahm incorporate Five-Shu points.
Attempting Shudo Denmei’s method [11] for treat-
ment may be worthwhile, even though more veri-
fication is necessary, as the use of root treatment
and symptomatic treatment, as well as comparing-
pulse diagnosis, may be a good treatment approach.
Sa-Ahm’s treatment, as well as Kim’s, can be con-
sidered root treatment from the viewpoint of Shudo
Denmei.
Broadly speaking, if Sa-Ahm Five Element acu-
puncture is used together with symptomatic treat-
ment, it may provide a more ideal acupuncture
treatment that could control and harmonize the
function and flow of Qi and blood.
Ross [3] suggests two main guidelines for the use
of the Five Element system [3]. This system should
be used if there is an energy block between two or
more organs and if there is correspondence with
the traditional function of the points. As the Five
Element system is for interior conditions, it is not
appropriate to treat exterior conditions such as
wind, cold, wind heat and summer heat, as well as
channel problems in which there is no organic in-
volvement. The Five Element system is not so effec-
tive in the case of severe deficiency, severe acute
excess, Yin-Yang pair imbalances, mixed deficiency
and excess in one organ, stagnation in the joints, and
stagnation at and between energy centers.
Ross [3] further explains that the Five Element
system can be used either alone or in combination
with other methods of point choice. However, the
other methods of point choice used must be second-
ary, and in harmony with, the Five Elements.
Even though Ross’ theory seems to be similar to
Sa-Ahm’s, Sa-Ahm used the Five Element system in
all diseases, including difficult cases that Ross asserts
are not appropriate [3].
Sa-Ahm acupuncture has also been viewed as a
four-needle technique to be used in “Five Element
constitutional acupuncture” for transferring qi from
one organ to another [5]. This would be a rare case
Five Element acupuncture
where the practitioner is unable to harmonize the
qi of two elements along the Sheng cycle.
The limitation of Five Element treatment have
been described as “not applicable to the use of the
secondary vessels and eight extraordinary meridi-
ans, and since the latter constitute the bulk of the
energetic system of acupuncture, Five Element
treatment strategies apply only seldom. The two
dominant styles of practice in this country, TCM
and Five Element acupuncture, both emphasize
the ZangFu (called Officials by Five Element prac-
titioners of the Worsley school) and the regular
meridians only and ignore the complex surface and
primal energetic networks, which, taken as a whole
with the regular meridians, constitute human en-
ergetics. In this sense, they are “disembodied ap-
proaches to acupuncture” [19].
Interestingly enough, Japanese acupuncturist
Kiiko Matsumoto and American acupuncturist Stephen
Birch have collaborated to write a book named Five
Elements and Ten Stems [20]. The book contents
are based on Nan Ching’s theory [21], diagnostics
and practice. The essence of diagnosis is rooted par-
ticularly in pulse diagnosis combined with traditional
procedures such as observation, hearing, question-
ing and palpation of the abdomen. Their treatments
consist of meridian-element treatments using Sa-
Ahm’s method, called Yanagiya’s treatment, as well
as local point treatment. Meridian-element treat-
ment can be seen as a root treatment with local
acupuncture as a branch treatment. Matsumoto and
Birch conclude that we should not allow ourselves
to become blinded by the correspondences and
theories of the Five Element method. Their conclu-
sion also applies to Sa-Ahm acupuncture [20].
The eminent Korean practitioner Do-Won Kwon
[9] has used Sa-Ahm acupuncture in his Constitu-
tional Acupuncture but it seems to lack coherent
arguments, even though the use of acupuncture in
many diseases refractory to various forms of acu-
puncture, including Five Element and traditional
acupuncture styles, was upgraded. Kuon’s Consti-
tutional Acupuncture may need to be studied in
detail in future.
Applied Channel Theory in Chinese Medicine fo-
cuses on channel palpation in diagnosis and on stim-
ulation technique in treatment. This method uses
“point pairs” because these pairs are understood
as having specific effects on the Qi transformation
of one or more of the six channel systems, and the
points are the Five Transport, source, cleft and
collateral points [22].
Meridian acupuncture, which uses local-distant
acupuncture, has also been proposed because the
local points collect and stabilize the energy while
the distant points cause it to circulate [23]. The
two work together like a pitcher and catcher or a
211
wheel and axle. Median acupuncture is performed
by first selecting the local points, then determin-
ing the meridian most implicated in the condition.
Finally the distant points that best suit the condi-
tion are selected. This theory is different from
that of Japanese meridian therapy in that although
Japanese meridian therapy is based entirely on the
laws of the five phases, the term “meridian style
acupuncture” has been extended to mean any form
of acupuncture that derives its strategies from clas-
sical energetic theory as founded in the Nei Jing
and Nan Jing, rather than the theories of herbalism
or modern science.
In brief, we must apply pulse diagnosis, channel
palpation and meridian-style acupuncture together
with other procedures such as observation, hearing,
questioning and abdominal palpation prior to Sa-
Ahm acupuncture treatment, and also set up guide-
lines for differential diagnosis. Also, we can attain
more effective treatment if using Sa-Ahm Five
Element acupuncture and root treatment of merid-
ian therapy in order to correct imbalances, as well
as channel theory and meridian style acupuncture,
which use local-distal points, special points, and
symptomatic treatment of meridian therapy, in order
to correct interruptions in proper stimulation tech-
niques without being wholly bound to Five Element.
3.3. Perspectives from medical
acupuncture
The study of acupuncture using scientific models
allows us to understand the effects of acupuncture
treatment. Since the early 1970s, more than 500
randomized controlled trials have been performed
to study acupuncture in North America, Europe,
Australia, and New Zealand, mainly focusing on
treatment of pain conditions. Other well-studied
areas include emesis, ophthalmology and otolaryn-
gology, substance abuse, cerebrovascular illnesses,
neurological problems, gynecological complaints,
asthma, and gastrointestinal problems [24]. Recently
Cho et al [25] stated that, based on their knowledge
of Western medicine, it is hard to believe that acu-
puncture treats organ-related disorders and diseases
by direct control of organs. Acupuncture may first
stimulate or activate the corresponding brain cortex
via the central nervous system, thereby controlling
chemical or hormone release to the diseased or dis-
ordered organs for treatment. Corresponding brain
cortices and disease-related acupoints need to be
consistent and related in terms of known medical
techniques to increase the plausibility of the use
of acupuncture.
Yun-Tao Ma et al [13] have developed a unique
treatment protocol, the Integrative Neuromuscular
Acupoint System (INMAS), which is a result of the
212
biomedicalization of traditional acupuncture, that
also succeeds in maintaining the essence of tradi-
tional oriental medicine. The INMAS makes it pos-
sible to succeed in providing both a standardized
treatment protocol that Western scientific medicine
demands and the adjustable personalized approach
of oriental medicine. INMAS has all the characteristics
required for a clinical procedure. First, simplicity,
the whole procedure from evaluation of the pa-
tient to insertion of needles can be performed in a
very short time in the clinic. Second, reproducibil-
ity, the procedure and therapeutic results are reli-
able and reproducible by any practitioner, beginner
or experienced. Third, predictability, this method
enables the practitioner to predict the results of
the treatment. The mechanism behind the clinical
effects of acupuncture needs to be investigated
from a neurobiological standpoint.
The “law” of Five Elements has been criticized
as an uncompromising model of dynamic relations
within the body, but is restored when it is consid-
ered as a method of systemic and organized expres-
sion of organic and clinical reality [26]. In the field
of acupuncture, we find it difficult to accept the
Five-Shu points and their therapeutic use according
to the “law.” The Five Elements in Chinese medi-
cine, even more than the Five-Shu points of acu-
puncture, are not part of the basic nucleus, but it
is necessary to examine this concept further.
The five phases are often used to describe clin-
ical processes and relationships to help in the con-
ceptualization of proper treatments [24]. It is an
explanatory theory and is not meant as a binding
doctrine, though all East Asian traditional physicians
recognize five phases as an important vocabulary
in their semantic network, theoretical perspective,
and clinical practice. Five Element treatment must
include the use of the secondary vessels and Eight
Extraordinary Meridians [19]. The Five Element treat-
ment is only part of acupuncture and must be viewed
as part of acupuncture overall.
Huang Long-xiang has stated “Clinical realities
that did not fit into an existing theory of Chinese
Medicine were often suppressed to ensure continu-
ity of the theories in a style that the Chinese call
‘cutting the foot to fit the shoe’” [27].
The most valuable discovery in acupuncture the-
ory is the interrelatedness between parts of the body
surface and between parts of the body surface and
the internal organs. These are the “immortal pearls”
of classic acupuncture.
Acupuncture does not treat any particular pa-
thological symptom but normalizes physiological
homeostasis and promotes self-healing [13]. Thus
acupuncture, in terms of its therapeutic mechanisms,
is nonspecific and does not target any particular
symptom or diseases but treats the body as a whole.
C.B. Ahn et al
Understanding this nonspecific nature of acupuncture
can provide an answer to the puzzling question:
what symptoms and diseases can acupuncture treat?
As a therapy, the efficacy of acupuncture de-
pends on the ability to heal symptoms and maintain
the self-healing potential in each patient. Sa-Ahm
acupuncture did not show a significant effect on
pain relief in osteoarthritis of the knee joint com-
pared to the sham group [28]. This result could be
interpreted that acupuncture, even Sa-Ahm acu-
puncture, cannot effectively treat joint disease,
but more similar trials are needed to establish this
conclusively.
All reviews seem to agree with the NIH Consen-
sus Panel that one of the advantages of acupuncture
is that the incidence of adverse effects is substan-
tially lower than that of many drugs or other ac-
cepted medical procedures used for the same
condition. Both sides of East-West dialectic un-
doubtedly have more to learn from each other and
this cooperation needs to be expanded upon [24].
As scientific mechanisms behind acupuncture are
being investigated at a surprising rate, and given
that the Five-Shu points and Five Element theory
are difficult to accept in clinical practice from a
Western perspective, the need for evidence-based
medicine is imperative and essential in relation to
Sa-Ahm Five Element acupuncture. Therefore, the
clinical verification of acupuncture treatment must
be made by comparing the effects of Sa-Ahm acu-
puncture with acupoint efficacy and combined
treatment.
4. Conclusion
When considering congenital energy, the Five-Shu
points account for powerful polarity and energetic
action, as they occupy a larger area in the cortical
representation of the postcentral sensory gyrus in
the brain and contain more sensory receptors.
Five-Element acupuncture consists of tonifica-
tion and sedation using Five-Shu points. Five Element
acupuncture, also known as “tonification and se-
dation in self-meridian” on the basis of the crea-
tion cycle, was first proposed by Gao-wu during
the Ming dynasty in China. Sa-Ahm developed this
technique further by extending it into another me-
ridian and using the destroyer cycle in self- and
other-meridians.
Original Sa-Ahm Five Element acupuncture can
be used from the perspective of ZangFu, disease
etiology, imbalanced Yang and Yin, the mind-only
theory and the comparing-pulse diagnoses such as
Jae-Won Lee and Dong-Pil Kim.
The use of Five Element acupuncture can be
applied from the teachings of original Sa-Ahm
 Five Element acupuncture
acupuncture, Japanese Meridian Therapy, channel
palpation, meridian-style therapy and constitutional
acupuncture.
In cases of interruption, acupoints are selected
based on local and special effects in correlation
with efficacy. We select Five-Shu points for either
deficiency or excess in relation to tonification and
sedation in cases of imbalance. Overall acupuncture
treatment that covers the treatment of interrup-
tions and imbalances of illnesses should be selected.
For example, more effective treatment may be
achieved if we use Sa-Ahm acupuncture as a root
treatment to correct imbalances but then combine
it with meridian style acupuncture, channel therapy
acupuncture (which uses local-distal points), spe-
cial points, or symptomatic treatment meridian ther-
apy, as branch treatments, to correct interruptions
in proper stimulation technique.
Results from clinical studies to compare the
results and efficacy of treatments, i.e., those of
Five Element treatment and those of combined
treatments, are required in future to determine
evidence-based practice. Investigation into the sci-
entific mechanisms behind the efficacy of acupunc-
ture should also continue.
Acknowledgments
This study was supported by a grant of Dongeui
University (2010AA113).
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